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Pupil Dilation Visual Field Screenings and the doctor’s standard evaluation examine your central retina, the most important area. When the pupil is small, the doctor is unable to examine the far peripheral areas, or outskirts of the retina. Therefore, many types of eye diseases, such as retinal detachments, holes, tears, and ocular tumors, can remain hidden, and many times occur without symptoms. Eye drops are used to widen the pupils to allow the doctor to view the entire retina. Eye drops may also be necessary to assist in the determination of the eye glass prescription, especially in children. Dilation is recommended for all patients, please answer the questions below: Yes___ No___ This is your first examination or you have not been dilated in over 2 years Yes___ No___ You are highly nearsighted (-5.00 D and over) Yes___ No___ You have Diabetes, High Blood Pressure, or problems affecting the eyes Yes___ No___ You have suffered recent head or eye injury, or suffer from headaches Yes___ No___ You have experienced sudden onset of “floaters” or “flashes of light” Yes___ No___ If you are over 55 years old Dilation drops widen the pupils in approximately 15 minutes, and the examination takes about 5 minutes. The drops wear off in 2-4 hours. Side effects of the drops include light sensitivity (complementary sunglasses provided if needed) and near vision blur (distance vision is relatively unaffected-YOU CAN STILL DRIVE-but having a driver is helpful). Some eyes may not be suitable for dilation, and your doctor may advise not to have this procedure. If you have any questions regarding this procedure, please ask your doctor. Please initial below: _____ I have read the above description, understand the procedure and agree to have pupil dilation. _____ I have read and understand the above information and DECLINE to have pupil dilation. (Despite your note to decline, your doctor may still recommend this procedure once in the examination room). Dr. Jennifer Geertz and Associates Independent Doctors of Optometry 9450 W. Joliet Road Hodgkins, Illinois, 60525 (708) 387-2190, (708) 387-2292 Fax Dr. Jennifer Geertz HIPPA Coordinator/Contact Person HIPPA COMPLIANCE ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I have received a copy of Jennifer Geertz, O.D. and Associates Notice of Privacy Practices. DATE_______________ Patient Name: _________________________________ Patient, Parent, or Guardian Signature: ___________________________________ *I authorize release of all information related to the claim(s) to all authorized parties (for insurance claims and billing purposes only). I fully acknowledge that I am responsible for any amount not paid by my insurance carrier. Signature_________________________________Date_____________